S.B. 85

1

MEDICAID COST CONTROL AMENDMENTS
2 2012 GENERAL SESSION
3 STATE OF UTAH
4 Chief Sponsor: Allen M. Christensen
5 House Sponsor: ____________
6
7 LONG TITLE
8 General Description:
9 This bill amends the Medicaid drug program and establishes a restricted account for
10 Medicaid drug cost savings.
11 Highlighted Provisions:
12 This bill:
13 . amends the Medicaid drug program to remove restrictions on the preferred drug list
14 program for psychotropic drugs;
15 . requires the department to authorize a nonpreferred psychotropic drug under certain
16 circumstances;
17 . establishes a restricted account for the cost savings from the preferred drug list for
18 psychotropic drugs; and
19 . requires a report from the Department of Health regarding cost savings to the
20 Medicaid drug program from the use of a preferred drug list.
21 Money Appropriated in this Bill:
22 This bill appropriates in fiscal year 2012-13:
23 . to the Department of Human Services, Division of Substance Abuse and Mental
24 Health, as an ongoing appropriation:
25 . from the Medicaid Cost Control -- Psychotropic Drugs Restricted Account,
26 $750,000, subject to intent language that the appropriation is non-lapsing and
27 shall be used to fund mental health centers.

28 Other Special Clauses:
29 None
30 Utah Code Sections Affected:
31 AMENDS:
32 26-18-2.4, as last amended by Laws of Utah 2009, Chapter 324
33 ENACTS:
34 26-18-2.7, Utah Code Annotated 1953
35
36 Be it enacted by the Legislature of the state of Utah:
37 Section 1. Section 26-18-2.4 is amended to read:
38 26-18-2.4. Medicaid drug program -- Preferred drug list.
39 (1) A Medicaid drug program developed by the department under Subsection 26-18-2.3
40 (2)(f):
41 (a) shall, notwithstanding Subsection 26-18-2.3 (1)(b), be based on clinical and
42 cost-related factors which include medical necessity as determined by a provider in accordance
43 with administrative rules established by the Drug Utilization Review Board;
44 (b) may include therapeutic categories of drugs that may be exempted from the drug
45 program;
46 (c) may include placing some drugs, except the drugs described in Subsection (2), on a
47 preferred drug list to the extent determined appropriate by the department;
48 (d) notwithstanding the requirements of Part 2, Drug Utilization Review Board, shall
49 immediately implement the prior authorization requirements for a nonpreferred drug that is in
50 the same therapeutic class as a drug that is:
51 (i) on the preferred drug list on the date that this act takes effect; or
52 (ii) added to the preferred drug list after this act takes effect; and
53 (e) except as prohibited by Subsections 58-17b-606 (4) and (5), shall establish the prior
54 authorization requirements established under Subsections (1)(c) and (d) which shall permit a
55 health care provider or the health care provider's agent to obtain a prior authorization override
56 of the preferred drug list through the department's pharmacy prior authorization review process,
57 and which shall:
58 (i) provide either telephone or fax approval or denial of the request within 24 hours of

59 the receipt of a request that is submitted during normal business hours of Monday through
60 Friday from 8 a.m. to 5 p.m.;
61 (ii) provide for the dispensing of a limited supply of a requested drug as determined
62 appropriate by the department in an emergency situation, if the request for an override is
63 received outside of the department's normal business hours; and
64 (iii) require the health care provider to provide the department with documentation of
65 the medical need for the preferred drug list override in accordance with criteria established by
66 the department in consultation with the Pharmacy and Therapeutics Committee.
67 (2) (a) For purposes of this Subsection (2)[,]:
68 (i) "Immunosuppressive drug":
69 [(i)] (A) means a drug that is used in immunosuppressive therapy to inhibit or prevent
70 activity of the immune system to aid the body in preventing the rejection of transplanted organs
71 and tissue; and
72 [(ii)] (B) does not include drugs used for the treatment of autoimmune disease or
73 diseases that are most likely of autoimmune origin.
74 (ii) "Psychotropic drug" means the following classes of drugs: atypical anti-psychotic,
75 anti-depressants, anti-convulsant/mood stabilizer, anti-anxiety, Attention Deficit Hyperactivity
76 Disorder stimulants, or sedative/hypnotics.
77 (iii) "Stabilized" means a health care provider has documented in the patient's medical
78 chart that a patient has achieved a stable or steadfast medical state within the past 90 days using
79 a particular psychotropic drug.
80 (b) A preferred drug list developed under the provisions of this section may not
81 include[:(i) a psychotropic or anti-psychotic drug; or (ii)] an immunosuppressive drug.
82 (c) The state Medicaid program shall reimburse for a prescription for an
83 immunosuppressive drug as written by the health care provider for a patient who has undergone
84 an organ transplant. For purposes of Subsection 58-17b-606 (4), and with respect to patients
85 who have undergone an organ transplant, the prescription for a particular immunosuppressive
86 drug as written by a health care provider meets the criteria of demonstrating to the Department
87 of Health a medical necessity for dispensing the prescribed immunosuppressive drug.
88 (d) Notwithstanding the requirements of Part 2, Drug Utilization Review Board, the
89 state Medicaid drug program may not require the use of step therapy for immunosuppressive

90 drugs without the written or oral consent of the health care provider and the patient.
91 (e) The department shall grant a prior authorization for a psychotropic drug that is not
92 on the preferred drug list if the health care provider has documentation related to one of the
93 following conditions for the Medicaid client:
94 (i) a trial and failure of at least one preferred agent in the drug class, including the
95 name of the preferred drug that was tried, the length of therapy, and the reason for the
96 discontinuation;
97 (ii) detailed evidence of a potential drug interaction between current medication and
98 the preferred drug;
99 (iii) detailed evidence of a condition or contraindication that prevents the use of the
100 preferred drug;
101 (iv) objective clinical evidence that a patient is at high risk of adverse events due to a
102 therapeutic interchange with a preferred drug;
103 (v) the patient is a new or previous Medicaid client with an existing diagnosis
104 previously stabilized with a nonpreferred drug; or
105 (vi) other valid reasons as determined by the department.
106 (f) A prior authorization granted under Subsection (2)(e) is valid for one year from the
107 date the department grants the prior authorization and shall be renewed in accordance with
108 Subsection (2)(e).
109 (3) The department shall report to the Health and Human Services Interim Committee
110 and to the Health and Human Services Appropriations Subcommittee prior to November 1,
111 [2010] 2013, regarding the savings to the Medicaid program resulting from the use of the
112 preferred drug list permitted by Subsection (1).
113 Section 2. Section 26-18-2.7 is enacted to read:
114 Part 2. Restricted Account
115 26-18-2.7. Medicaid Cost Control -- Psychotropic Drugs Restricted Account.
116 (1) There is created a restricted account within the General Fund known as the
117 "Medicaid Cost Control -- Psychotropic Drugs Restricted Account."
118 (2) Any money the Medicaid program saves as a result of psychotropic drugs being
119 added to the preferred drug list, up to $750,000, shall be deposited by the Medicaid program
120 into the restricted account.

121 (3) As funds are available in the restricted account, up to $750,000 shall be
122 appropriated to the Department of Human Services, Division of Substance Abuse and Mental
123 Health, for mental health centers.
124 Section 3. Appropriation.
125 Under the terms and conditions of Title 63J, Chapter 1, Budgetary Procedures Act, the
126 following sums of money are appropriated from resources not otherwise appropriated, or
127 reduced from amounts previously appropriated, out of the funds or accounts indicated for the
128 fiscal year beginning July 1, 2012 and ending June 30, 2013. These are additions to any
129 amounts previously appropriated for fiscal year 2013.
130 To Department of Human Services - Division of Substance Abuse and Mental Health
131 From Medicaid Cost Control -- Psychotropic Drugs Restricted Account

$750,000

132 Schedule of Programs:
133 Mental Health Centers $750,000
134 The Legislature intends that, under Section 63J-1-603 of the Utah Code, appropriations
135 under this section not lapse at the close of fiscal year 2013 and shall be used by the Division of
136 Substance Abuse and Mental Health to fund mental health centers.




Legislative Review Note
as of 2-7-12 11:20 AM

Office of Legislative Research and General Counsel